The Global Gag Rule and the Implications for Sexual and Reproductive Health

13 March 2018

Written by Jenna Joffe on behalf of Creative Consultants & Development Works

In his first week in office in 2017, United States President Donald Trump issued a memorandum to reinstate and expand the “Global Gag Rule”. He announced that he would be severing all US funding to organisations that “perform [or] actively promote abortion as a method of family planning.” This policy prevents foreign NGOs from being granted US health funding if they use funds to provide information about abortion, counsel individuals about abortion, refer them for an abortion, provide abortion services, or advocate for abortion laws. By law, federal money in the US can’t be spent on abortions, but the expansion of the Rule allowed for the ending of US grants for organisations that were in any way “pro-abortion” or that offer holistic sexual and reproductive healthcare in their own countries outside of the US. In effect, the policy applies not only to recipients of family planning funding, but also to many recipients of global health assistance provided by all US government departments or agencies.

The Rule is not only an impediment on family planning services, but given the integrated nature of these services, the policy inadvertently attacks various other public health issues, especially those affecting women and children. The US is the world’s largest source of global health financer and implementer of global health programmes. The Rule reportedly extends restrictions to an estimated $8.8 billion in US global health assistance. Beyond affecting funding support for family planning and reproductive health, the restrictions have implications for services related to maternal and child health, nutrition, HIV/AIDS , prevention and treatment of tuberculosis (TB), malaria, infectious diseases, and neglected tropical diseases.

Doctors Without Borders (MSF) have expressed concern about the effect the policy will have on women’s health and progress in global health endeavours, particularly efforts charged towards reducing maternal mortality related to unsafe abortions. According to the World Health Organisation (WHO), unsafe abortions account for approximately 13 percent of maternal deaths internationally. It is expected that the policy will create a market for backstreet abortion providers: Research indicates that 21 million women who get abortions go to illegal providers, and approximately 78 000 women die from complications. As such, the impact of the policy is potentially deadly to millions of women globally.

The Global Gag Rule has serious negative implications for women’s health and lives in South Africa, who is a major recipient of US federal funding. In 2016, 90% of the aid South Africa received allocated to healthcare was from the US (approximately 1.3 billion). Sexual reproductive health programmes sponsored by US funding will be negatively affected, including programmes funded by major donors such as PEPFAR, USAID, and the Global Fund to Fight AIDS, TB and Malaria. South Africa is one of few African countries which have liberal abortion laws. Many organisations in South Africa who provide abortion services or information, or who advocate for abortion services, now cannot apply for funding currently on offer from the US to address other related issues including gender-based violence (GBV) and HIV, despite South Africa bearing the world’s largest burden of HIV (with young women and girls disproportionately affected) and some of the highest rates of GBV. This is also despite the fact that South African women have the right to access safe and legal abortions as guaranteed by the Choice of Termination Pregnancy Act (1997). According to Sonke Gender Justice, this Act has produced significant improvements in women’s health and wellbeing. High morbidity from incomplete abortions halved between 1994 (16.5%) & 2000 (9.5%), permanent genital injuries from incomplete abortions decreased from 3.2% (1994) to 0.6% (2000), and there was a 91% reduction in deaths to women due to abortion.

Activists say a clause in the policy may allow some organisations, such as those in South Africa, potential exemption, although it still does not allow them to provide abortions. US funding guidelines state that when local laws require health workers to provide counselling and referrals for abortions, they may continue to do so without violating the policy. As such, the Rule should be null for healthcare workers in South Africa, as they are obligated to counsel and refer women under domestic laws, ethics guidelines and the Constitution. The policy cannot violate the laws of an independent state. However, Deputy Director of Public Policy for the Amfar warns that the US may still withdraw future funding from organisations and government who exercise their rights under the Rule.

The Global Gag Rule is also not necessarily supported by public health research. A 2011 study found that enforcement of the policy by the George W Bush administration led to an increase in abortion rates in sub-Saharan Africa, which was likely a result of decreased access to contraceptives and a consequent increase in unwanted pregnancies. A study conducted in Ghana found that, because of declines in the availability of contraceptive services as a result of the Gag Rule, both fertility and abortion rates were higher during the administrations that reinstated the Gag Rule than during non-gag rule years in rural and poor populations. The Guttmacher Institute’s report on the Global Gag Rule has stated “in reality, attempts to stop abortion through restrictive laws – or by withholding family planning aid – can never eliminate abortion, because those methods do not eliminate women’s need for abortion”. Rather, the policy results in women being left with few safe options when it comes to their reproductive health.

Two of the world’s largest family planning organisations, International Planned Parenthood Federation and Marie Stopes International have reportedly announced that they would no longer be accepting US donations. By the end of 2020, Marie Stopes estimates that the reduction in services will result in 110 000 unintended pregnancies and 32 000 unsafe abortions in Zimbabwe alone. In Kenya, Family Health Options (the local affiliate of Planned Parenthood and the country’s oldest family planning clinic) has been forced to reduce or end outreach programmes that were reaching approximately 76,000 women every year, and has had to close one of its clinics.

In little over one year into Trump’s presidency, it is too early to say with specificity what the impact of the Rule will be. However, evidence from previous Gag Rule administrations have consistently shown negative consequences for the sexual and reproductive health of women and girls. Unless the Rule is again revoked (likely by Democrats, as previous trends of change in office have indicated), recipients of US federal funding are being forced to make a difficult choice: A choice between accepting US federal funding and refusing women services and information about abortions (even in countries where this is legal and when such services are funded by other donors), or declining US funding in favour of giving women information about their reproductive health, rights and choices, but therefore forfeiting US funding for crucial non-abortion related health initiatives, including HIV, TB and GBV. It is a compromise that service providers must make carefully if they are to ensure the least impact on the communities they serve.